足母甲瓣游离移植术中趾静脉相关问题探讨

Discussion related to the vein of toe in toe free flap transplantation

目的探讨躅甲瓣游离移植再造拇指术前应用数字化技术明确躅趾静脉走行的临床意义。方法自2012年6月至2013年3月，对拇指不同程度缺损拟行游离躅甲瓣移植再造拇指术的患者22例，术前进行供、受区CT扫描，通过CT血管造影数字化三维重建技术获得患者供区动、静脉血供三维图像，术前明确供区第一跖背动脉的分型、躅趾静脉的分布规律及走行。采用计算机辅助解剖建模分析供区血供三维图像、受区缺损参数，根据数字化三维重建技术指导供区的手术设计。按设计方案施行游离躅甲瓣移植再造拇指术。结果64排双源螺旋CT能良好显示躅趾静脉的大小、分布规律及走行，躅趾静脉分深、浅两组，其中浅静脉管径粗大，是躅址的主要回流静脉。躅趾趾背静脉起自甲床的静脉丛，其沿趾背后行至跖趾关节附近，组成3—4支跖背静脉后注人足背静脉弓，其走行规律遵循：集中→分散→交通→再分散的形式。大隐静脉起自足背静脉弓的内侧端，在内踝前沿小腿内侧上升，收集3条较大的属支：内踝支-小腿前支-小腿外侧支。小隐静脉起自足背静脉弓的外侧缘，绕外踝后方上行至小腿后面，后注入静脉。结论应用蹿甲瓣移植再造拇指，明确躅趾静脉的走行及分布规律，结合数字化三维重建技术进行手术设计，有利于静脉回流，降低血管危象的发生，从而提高躅甲瓣移植术的成活率。

Objective To explore the clinical value of applying digital technology to make the course of toe vein clear before toe free flap transplantation for thumb reconstruction. Methods Before operation, scan the donor and recipient site by CT, and apply digital three-dimensional CT angiography reconstruction technology to got three- dimensional images of the arteries and veins in the donor site for 22 various defected thumbs which were going to have toe free flap transplantation operation, thus indentifyed the types of FDMA and the distribution and course of the toe vein from June, 2012 to March,2013. Used computer assisted anatomical modeling to analyze three-dimensional images of blood supply of the donor site and degree of defect of the recipient site and guide the operative design in the donor site according to the digital three-dimensional reconstruction technology. Conducted toe free flap transplantation for thumb reconstruction in accordance with the design. Results It shows that 64-slice dual-source spiral CT could well display the size, distribution and course of toe vein. The toe veins were clarified to two groups, deep one and superficial one whose diameter was larger and was the main reflux vein of the toe. Dorsal vein of the toe origind from venous plexus in the nail bed and it travels along the back of the toe to reach to the near side of metatarsophalangeal joint. And then it b^-omes three to four dorsal metatarsal veins to infused dorsal venous arch of foot. The rule of its course was： centralize-decentralize-connect-decentralize again. The great saphenous vein origins from the inner side of dorsal venous arch of foot, rises along the crus before malleolus medialis and collect three larger tributaries： medial malleolar branches- anterior crural branch-outside crural branch. The small saphenous vein derives from the outside of dorsal venous arch of foot and winds behind lateral malleolus up to the back of the curs and infuses to the vein. Conclusion It is useful for venous return, reducing the incidence of vascular crisis by applying toe flap to reconstruct thumbs and clarifying the course and distribution of toe vein with the aid of digital three-dimensional technology to design operation, thus improving the survival rate of toe flap transplantation.